Healthcare Provider Details

I. General information

NPI: 1063907889
Provider Name (Legal Business Name): MR. MICHAEL VAMVAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MR. MICHAEL VAMVAS

II. Dates (important events)

Enumeration Date: 06/25/2018
Last Update Date: 06/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 SALVATORE DR
LAKEWOOD NJ
08701-5898
US

IV. Provider business mailing address

31 SALVATORE DR
LAKEWOOD NJ
08701-5898
US

V. Phone/Fax

Practice location:
  • Phone: 732-337-0259
  • Fax: 848-245-9821
Mailing address:
  • Phone: 732-337-0259
  • Fax: 848-245-9821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: